by David Wadsworth
As we have learned in this series of posts, persistent pain has many complex causes and is therefore difficult to treat. We know so far that persistent pain is more likely to be caused by dysfunction than pathology.
To refresh your memory dysfunction means something is tight, loose, weak, inhibited or tense . Dysfunction can be reversible, and causes about 90% of persistent spinal pain.
Pathology indicates structural damage that usually is visible on a scan (like a fracture, degenerative joint or disc, torn tendon). In many cases involving persistent pain, pathology is a result of years of untreated or inadequately treated dysfunction.
So what else is there to know about persistent pain? Well here is where it can get even more complex.
There are literally thousands of different types of dysfunction that can contribute to persistent pain. If we think about joint pain in your spine, the pain may just involve the musculoskeletal system (joints, muscles, ligaments). At the most basic level if we were to consider joints alone there are many types of joint dysfunction, so even if just one system is involved your practitioner will need multiple skill-sets to deal with joint pain.
If we expand our appraisal of spinal pain to consider a more complete view of all the possible causes of what might be labelled “joint” pain, we can begin see a perspective that includes dysfunction in all systems of the body and not simply the joints alone. How can this occur? One explanation is that each joint or segment of the spine receives neural feedback from many different structures arising from the many different systems of the body. So each joint or spinal segment can be influenced and altered by many different things, involving any system of the body related to that segment. The spine will react to any irritation or painful incoming nerve signals by increasing the tension (tone) of the muscles at those segments, causing the spinal joints to stiffen up and movement to be restricted, potentially leading to secondary pain in the joint or muscles affected. In other words, the joint or muscle dysfunction your practitioner may identify when they examine you might just be a secondary phenomenon with the primary cause located elsewhere, perhaps in another system of the body.
The body systems include:
Any one of these body systems may have a level of dysfunction that can contribute to your pain, whether this pain is in the spinal column or the limbs.
To illustrate this concept let’s consider a real world example. A 63-year-old-man sought my care for left shoulder pain. He was a plasterer by trade and used his arms a lot for work. I had seen him five years previously for a left rotator cuff tear in his shoulder, diagnosed via an ultrasound scan, after which time he became a foreman to reduce the load on his shoulder. On this occasion he sought my care for what he felt was exactly the same shoulder pain. His pain began after he did some unusual loading on his shoulder – he went back to work plastering for three days helping his workmen plaster the ceilings on a new apartment block. The only other new thing which had happened in the five years between shoulder complaints was that he had a double hernia repair (abdominal surgery). Sounds a lot like he had a recurrence of rotator cuff pain in his left shoulder again, doesn’t it? He certainly thought so.
However, good practice requires all other possibilities to be eliminated before jumping to a conclusion regarding diagnosis. A physical examination demonstrated other possible factors at play. As a result of his hernia repair, abdominal adhesions had formed and pulled at the bottom of his stomach (arrows in diagram below), overstretching the stomach in a condition known as “gastric ptosis”. The stomach can refer pain into the left shoulder as shown in the second diagram. We trialed treating the stomach adhesions first, as a short treatment will typically give a good indication as to whether this was related. After about 15 minutes of very gently stretching the adhesions at the bottom of his stomach, his shoulder was pain-free during all movements. It was no longer tender to touch. In other words he had referred tenderness as discussed in an earlier post in this series. This fellow has remained pain free since his first treatment. Although he had no stomach symptoms, reaching overhead when plastering required his spine to extend and his organs (including the stomach) to move upwards. Since he had adhesions holding his stomach down, the additional overstretching of the stomach reached a point where it caused enough irritation to register as pain. Since the stomach can refer into the shoulder, he felt shoulder pain, especially when reaching overhead. Stretching the adhesions to make them longer and reduce the pull on the stomach was enough to eliminate his symptoms.
Arrows show the pull of adhesions on the stomach Area of referred pain from the stomach
As you have by now gathered, there are newer methods for practitioners to assess and treat all of the different systems in the body. For example, your practitioner will require skills that extend beyond joint mobilisation or manipulation, or the many forms of muscular massage, to manage this large range of possible dysfunctions. These skill sets or treatment approaches (sometimes called paradigms) may include strain-counterstrain, muscle energy technique, visceral manipulation (several approaches exist here), trigger point therapy (of which there are also several methods), capsular stretching, postural and muscle imbalance approaches and the related rehabilitative and resistance training methods used to manage these components.
If you want to get on top of your persistent pain, you may need to consult a professional who has a broad enough skill set to help manage your pain and all of the different possible causes.